Mike  Pence,  Governor  State  of  Indiana  

 Indiana  Family  and  Social  Services  Administra4on  

 

2013 Indiana Health Coverage Programs Annual Seminar

Care Select 101:

Indiana Care Select Program Overview

Presented by MDwise, Inc. and

ADVANTAGE Health Solutions, Inc.

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PCS0148 (9/13)

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Agenda

•  Program Goals •  Member Eligibility Requirements •  Disease Management Focus •  Complex Case Management •  General Prior Authorization Guidelines •  Right Choices Program (RCP) •  Questions & Answers

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Program Goals

A disease management program focusing on members with chronic conditions to help them achieve: –  Improved health status –  Enhanced quality of life and autonomy –  Improved member safety –  Adherence to treatment plans

About 32,000 Medicaid members are currently enrolled in the disease management program.

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Member Eligibility

Care Select Care Management Organizations (CMOs) –  ADVANTAGE Health Solutions, Inc. –  MDwise, Inc.

State-wide Populations Served –  The aged (if not eligible for Medicare), blind members, and

physically and/or mentally disabled members (collectively known as the ABD population)

–  Wards of the court and foster children –  Children on adoption assistance

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Member Eligibility Eligible Care Select Member conditions

–  Asthma –  Diabetes –  Congestive Heart Failure –  Coronary Heart Disease –  Hypertension –  Chronic Kidney Disease –  Severe Mental Illness (SMI) and Depression –  Serious Emotional Disturbance (SED)

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Member Eligibility Member Opt-out Process

–  Members can opt-out if they are eligible to participate in the Care Select program

–  Members who opt-out will be enrolled in Traditional Medicaid –  Members with a chronic disease who opt-out can opt back in by

contacting Maximus (State’s enrollment broker)

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Member Eligibility PMP Selection

–  New members who don’t opt-out will have 60 days to choose a PMP

–  If no selection made, member will be auto-assigned to a PMP •  Member’s previous PMP in same CMO •  Member’s previous PMP/group in another CMO •  Member’s previous CMO •  Family member’s previous PMP •  Default

–  Member can change PMP assignment by contacting their CMO or Maximus

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Member Eligibility Nominating members for Care Select Participation

–  PMPs can contact Maximus to refer a Traditional Medicaid member for inclusion in the Care Select program

•  Use the Provider Referral Form located on the “Forms” page at www.indianamedicaid.com (fax number is listed on the form)

–  Member must meet Care Select program eligibility requirements

–  Maximus will outreach to the member to opt-in or opt-out

•  IHCP Bulletin BT201130 (June 30, 2011)

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Disease Management Focus •  Members will have access to additional

education resources within the CMO •  Increased compliance with disease

management treatment plans including medication compliance and appropriate preventative care visits

•  Disease specific assessments and care plans •  Goals: individualized and preventive care

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Step  1.  Assess  Member  Needs  

Step  2.  Design  Care  

Plan  

Step  3.  Coordinate  

Care  

Step  4.  Measure  Results      

Disease Management Focus

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Disease Management Focus

Types of Interventions: –  Population-Based Interventions

–  Member Specific – Disease Management Interventions

–  Member Specific – Care Management Interventions

Note: These interventions are based on the member’s established level of care at the time of the intervention.

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Disease Management Focus Levels of Care:

Care Level 1- initial level applied to all newly enrolled members with the primary focus of initial member outreach & assessment

–  Established specific chronic disease(s) –  Assessment to determine appropriate care level

•  Once assessment completed member becomes either level 2 or 3 –  Evidence based disease management mailings –  Evidence based disease management interventions once per

year –  Population based interventions –  No specific DM care plan

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Disease Management Focus Initial Screening •  Performed using the State’s approved health risk assessment to

identify the member’s immediate physical and/or behavioral health care needs, as well as the need for Disease Management, Care Management, and/or Care Coordination

•  Conducted by phone or by mail •  CMOs will:

–  Review member’s claims history –  Identify any access or accommodation needs, language barriers, or

other additional assistance needs –  Identify members who have complex or serious medical conditions

which require an expedited PMP appointment

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Disease Management Focus

Member Assessment •  Initial screening and stratification must be completed within 120 days

of a member’s enrollment in the CMO •  All members can be reassessed when

–  Indicated by a change in clinical status –  Identification of a new care gap –  Indicated by utilization or claims review –  Notification from the PMP –  Notification from member or member advocate –  Periodic reassessment may result in stratification to a new level

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Disease Management Focus

Levels of Care: Care Level 2 – member relatively stable medically and

demographically –  Member educated about chronic condition –  Care plan based on clinical guidelines –  Design goals and health outcomes with member –  Identify and address any unique health needs/barriers –  Monthly phone call from disease manager –  Annual PMP case conference upon request

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Disease Management Focus

Levels of Care: Care Level 3 – members who require disease management plus more intensive

care management –  Includes all elements of Level 1 and Level 2 disease management services –  Development of a care plan that includes a more comprehensive detailed

assessment that addresses the clinical, psychosocial, functional, and financial needs of the member

–  Will have one assigned care manager who serves as a primary point-of-contact responsible for coordinating with a team of health care providers from multiple disciplines to provide integrated care

–  PMPs, advocates, and persons involved in member’s care may contact the care manager for care coordination and consultation.

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Complex Case Management

Care Plan Development •  Data analysis and predictive modeling

–  Identify members at high risk for hospitalization or relapse –  Identify members at risk for high cost and/or high utilization in the future –  Identify gaps in current treatment approach and communicate findings

to the member’s PMP

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Complex Case Management

Care Plan Development •  Care Plan Information Sources – Levels 2 & 3

–  Gather information about existing care/case management plans being received; for example, through a CMHC

–  Collect and review: •  Medical and educational information •  Family and caregiver input •  Claims data •  Initial screening •  Medical records

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Complex Case Management

Monitoring –  Ongoing consultation with physical and behavioral health

providers –  Sharing of clinical information –  Gathering of information about the care plan’s activities,

interventions, and services –  Determine the care plan’s effectiveness in addressing care gaps

and reaching evidence based outcomes –  Update care plan as needed

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Complex Case Management

State Reporting –  Modify Level 3 members’ care plans via feedback from member,

families, PMP, BH and other providers –  On a regular basis (at least quarterly), the CMOs report the

overall success of the care management program to the STATE •  Performance data related to:

–  Quality of care management –  Medical necessity determinations –  UM management

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General PA Overview

There are two Care Management Organizations (CMOs): • ADVANTAGE Health Solutions, Inc. sm

• MDwise, Inc. Note: ADVANTAGE adjudicates all Traditional Medicaid, Medicaid Rehabilitation Option (MRO), and PRTF PA requests

By contract, the CMOs are responsible for:

• Processing PA requests • Making medical necessity determinations

• PA decisions based on OMPP approved guidelines • Notifying providers and members of the determination

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General PA Overview Make sure you’re using the official IHCP form!!

–  Universal PA form is to be used by all providers for all PA requests (except dental and pharmacy) for Traditional FFS PA, the CMO’s (Care Select) & MCE’s (HHW & HIP).

–  Forms available at www.indianamedicaid.com –  Provider PA decision letters sent to “mail to” address in IndianaAIM

or noted on PA request form (Note: Ensure “Mail to” address is updated).

–  Please refer to BT201045 for further information. Please note: The MCE Outpatient Therapy Request (OTR) PA form must

be used when requesting non-MRO behavioral health PA for HHW and HIP members.

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General PA Overview Required forms located at www.indianamedicaid.com in “forms”

•  Universal PA for medical and behavioral health (Care Select or Traditional Medicaid only)

•  Prior Review and Authorization Dental Request form •  System Update Form •  Certificate of medical necessity forms (i.e. oxygen, hearing aids, hospital

beds, etc)

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General PA Overview

Determine if a service or item requires PA in Traditional Medicaid and Care Select (CS):

•  Use the IHCP fee schedule: www.indianamedicaid.com. •  More information found in the IHCP Provider Manual Ch. 6, Indiana

Administrative Code (IAC), bulletins, banner pages, and newsletters.

•  Providers can review billing and coverage information in Ch. 8. •  Check PA status using PA inquiry function in Web interChange

PRIOR to contacting the CMO. •  Providers must submit PA supporting documentation via fax or mail.

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General PA Overview

Supporting PA Documentation •  PA must be submitted on the appropriate PA request form and be

supported by appropriate medical necessity documentation: •  Examples of Supporting Documentation:

–  certificate of medical necessity form –  treatment plan/plan of care –  physician order –  physician notes –  other documentation supporting medical necessity

Note: The CMOs retain the right to suspend a PA request to request additional information to make medical necessity determinations.

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Right Choices Program

The Right Choices Program (RCP) includes members who have shown a pattern of potential mis-utilization or over-utilization of services –  Non-emergent use of the ER –  “Drug seeking” behavior –  Resistance to PCP interventions

The RCP is: –  Not a loss of benefits –  Not a reduction in benefits –  Not a punitive action, but is a legal action

Note: Members are still eligible for all medically necessary IHCP services. However, those services must be ordered or authorized in writing by the member’s assigned PMP.

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Right Choices Program

The RCP identifies members appropriate for assignment and subsequent “lock-in” to: –  One Primary Medical Provider (PMP) –  One pharmacy –  One hospital

The goal of “lock-in” is to ensure members receive appropriate care and prevent members from mis-utilizing services. Note: The Right Choices Program applies to ALL Medicaid members (Care Select, Hoosier Healthwise, HIP, and Traditional Medicaid)

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Right Choices Program

The PMP manages the member’s care and determines whether a member requires evaluation or treatment by a specialty provider –  Referrals are required by the PMP for most specialty medical

providers (except self-referral services) •  The CMOs add those specific physicians (NOT groups) to the

member’s provider list in order for the specialty provider to be reimbursed

–  Referrals should be based on medical necessity and not solely on the desire of the member to see a specialist

–  Emergency services for life-threatening or life-altering conditions are available at any hospital, but non-emergency services require a referral from the PMP

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Right Choices Program

Self Referral Services

•  Behavioral Health (except prescriptions)

•  Chiropractic services •  Dental services (except

prescriptions •  Diabetes self-management

services •  Family planning services •  HIV/AIDS targeted case

management

•  Home health care •  Hospice •  Podiatric services (except

prescriptions •  Transportation •  Vision care (except surgery) •  Waiver service

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Right Choices Program

Adding Providers to a Right Choices Member’s “Lock-in” List –  Additional providers may be “locked-in”, either short-term or on an

ongoing basis, if the PMP sends a written referral to the CMO –  Providers may be “locked-in” for one specified date of service or for

any defined duration of time up to one year

The list of approved providers on a member’s “lock-in” list is available in Web interChange on the member’s eligibility profile. –  For Traditional Medicaid members, their profile will show they’re in the Right

Choices Program but NOT list who the “lock-in” PMP is. You will need to contact ADVANTAGE Health Solutions to determine which physician that is.

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Right Choices Program Referral Guidelines for the PMP •  Referrals must be faxed or mailed to the CMO •  Referrals may be legibly handwritten on letterhead or a prescription

pad, however they must include the following information: –  IHCP member’s name and RID –  First and last name and specialty of the physician to whom the member

is being referred –  Primary “lock-in” physician’s signature (not that of a staff member) –  Date and duration of referral

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ADVANTAGE ADVANTAGE Health Solutions –

Traditional FFS Attn: Right Choices Program P.O. Box 40789 Indianapolis, IN 46240 1-800-784-3981 Fax: 877-392-6894 ADVANTAGE Health Solutions -

Care Select Attn: Right Choices Program P.O. Box 40789 Indianapolis, IN 46240 1-800-784-3981 Fax: 877-392-6894

MDwise MDwise Care Select Attn: Care Management P.O. Box 44214 Indianapolis, Indiana 46244-0214 Phone: 1-800-356-1204 or 317-630-2831 Fax: 1-877-822-7187 or 317-822-7517

Right Choices Program Contact Information

ADVANTAGE Care Select: 1-800-784-3981

MDwise Care Select: 1-800-356-1204

CMO Contact Information

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Questions & Answers

Thank you for attending!

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